Persistence pays off when fixing the pieces to the continuum of care puzzle

Consider it a work in progress

Delivering and documenting patient education across the continuum of care is a challenge at many health care facilities. It is something that’s always going to be a work in progress, says Kay M.B. Thiemann, MBA, administrator at the Mayo Clinic Section of Patient Education, Patient Education Center in Rochester, MN. "At Mayo, our role is to do the best we can with the resources we have. We teach staff how to do good patient education and we will teach them again and keep coming back and improving as we go," she says.

Good patient education is provided across the continuum of care in many ways. There are educators at Mayo assigned to clinical areas who work with health care providers to create a patient education plan that meets the needs of both inpatient and outpatient providers.

The method used is similar to the direct patient teaching process where a patient’s learning needs are assessed, then a plan is developed and implemented, and followed by an evaluation, says Thiemann. "We do an assessment to determine what providers need to deliver good patient education, we write a plan, we implement the plan and get staff up to speed, then we look back to see if we made the mark or not," she explains.

For example, if during the assessment the educator determines that clinic staff need assistance with documentation of patient education, he or she would write into the plan that a certain percentage of time in 2002 would be devoted to staff development.

Chart audits available

Both inpatient and outpatient services document on the same patient and family education flow sheet, which is kept with the patient’s chart. To help clinical areas improve documentation, the education department provides chart audits for those who request it. "We give the leadership of the department the chart audit report and compliance is up to them," says Thiemann.

There are usually five to seven strategic objectives per patient education plan for a clinical area. In addition to staff development, the objectives might include the development of patient education materials or the development of a class.

Educators assigned to work with providers spend time in their clinical areas attending practice meetings and meeting with staff to listen to their concerns and inform them of available patient education services.

Staff awareness of patient education services is important. To meet the educational needs of expectant mothers, Sacred Heart Medical Center in Spokane, WA, developed teaching material, Precious Journey Notebook, that covers a woman’s educational needs throughout her pregnancy, says Sherry Maughan, RN, women’s services director. The notebooks are distributed to physician’s offices where they are given to patients when they are 20 weeks into their pregnancy.

When a patient is given the notebook, a postcard is sent to Sacred Heart with the patient’s name and contact information. That name is entered into a database, and at about 36 weeks of pregnancy, the couple is invited to the hospital for a pre-admit visit. (To learn more about the notebook, see "One book standardizes and consolidates teaching," in this issue.)

Slowly, providers are taking advantage of this educational service. When the booklets were first distributed, about 30% of maternity patients were coming to Sacred Heart for pre-admit visits. Last year, the number rose to 56% — a good jump since some of the women have already had babies and may not feel a visit is necessary, says Maughan.

In-sync education

The notebook, along with the education expectant mothers receive at the physicians office, provides the educational foundation that is built during the hospital stay. Education is reinforced again with postpartum follow-up calls.

"The notebook has helped standardize the information the patients are getting. They aren’t being told one thing by nurses in the outpatient clinics and something different by inpatient nurses. We provide a set of very consistent education direction," says Maughan.

In situations where there are care teams or clinical practice groups that cross from inpatient to outpatient and include home health, education can be very strong, says Zeena Engelke, RN, MS, patient education manager at the University of Wisconsin Hospital and Clinics in Madison.

"There is a better understanding of what is taught there and, as a result, even if the documentation is more fragmented, there is a mutual understanding of what has occurred. Therefore, it is easier to carry on the education from that point rather than starting from zero," she says. For example, at the University of Wisconsin, the pre-operative education for women having breast surgery is conducted in the learning center and augmented by inpatient or outpatient surgical staff and home health.

Build on previous training

In the clinic setting, it is important to have a clear picture of what the patient has been taught at previous visits so that staff can quickly reassess learning needs and move into new teaching to achieve new outcomes, says Engelke. For this type of teaching to take place in outpatient settings, outcomes of past teaching must be documented. For example, if the patient was taught to use a glucose meter and draw up and give insulin on a timely basis at his or her last appointment, the health care provider would know where to begin teaching at the next visit.

A documentation tool is used in University of Wisconsin Clinics to track outpatient education; however, if the visit is not primarily focused on teaching, it’s impractical to use it for every visit, says Engelke. Therefore, a stamp also can be used on history and physical notes to document barriers to learning, what has been taught, what teaching methods were used such as handouts or discussion, and the learner’s response.

Set up a referral system

When a topic is too complicated or too much time is needed to provide adequate education, a referral system can help. At Mayo, providers are encouraged to send the patient to the patient education center for a one-on-one educational consult or enroll him or her in one of the classes that are offered. "We have printed referral cards and some clinical areas can electronically order a class or an education consult for their patient. However, it is up to the provider [to decide]," says Thiemann.

The education department at Mayo develops educational strategies for the providers so they feel more confident in their patient education delivery. The department also provides teaching tools such as print materials and videos to help providers educate their patients in addition to providing classes and one-on-one teaching consults. They just implemented patient education grand rounds and on kick-off day, over 200 health care providers attended. The topic was learning-needs assessment, says Thiemann. (For more information on teaching staff to teach, see "Teaching skills every staff educator should master," in this issue.)


For more information about providing patient education across the continuum of care, contact:

  • Zeena Engelke, RN, MS, Patient Education Manager, University of Wisconsin Hospital and Clinics, 3330 University Ave., Suite 300, Madison, WI 53705. Telephone: (608) 263-8734. E-mail:
  • Sherry Maughan, RN, Women’s Services Director, Sacred Heart Medical Center, P.O. Box 2555, Spokane, WA 92200. Telephone: (509) 474-3713. E-mail:
  • Kay M.B. Thiemann, MBA, Administrator, Section of Patient Education, Patient Education Center, Siebens SL, Mayo Clinic, 200 First St., S.W., Rochester, MN 55905. Telephone: (507) 538-1122. E-mail: